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Introduction: The National Fire Protection Association (NFPA) reports that motor vehicle incidents are consistently the second leading cause of on-duty fire fighter fatalities. A NFPA 30-year study (1977-2006) reveals that only 13% of the 406 fatal crash victims were wearing safety restraints, and 45 fire fighters died when they fell from a moving apparatus. Methods: The NIOSH Fire Fighter Fatality Investigation and Prevention Program (FFFIPP) studies fatal fire fighter occupational incidents, with the goal of identifying effective prevention measures. Through on-site investigations, FFFIPP personnel collect agent, host, and environmental information from the pre-event, event, and post-event phases of the fatal incident. Results: A review of FFFIPP investigations from 1998 -2007 identified 63 motor vehicle related cases involving the death of 46 fire fighters where not being seated and restrained in a moving vehicle likely contributed to the fatality. Relevant findings from these investigations include: (1) fire departments often have established safety restraint standard operating procedures (SOPs) that are not enforced, and (2) there have been instances when fire fighters had to remove safety restraints to perform required tasks because of apparatus/equipment design and/or placement. Conclusions: Evidence collected during FFFIPP investigations suggests that fire departments must not only develop, but need to enforce SOPs that require all occupants in moving apparatus to be seated and restrained at all times the vehicle is in motion. Manufacturers, fire departments, and those who refurbish emergency vehicles must take into consideration all movements needed to reach equipment and ensure that safety restraints can be worn by all occupants when performing required tasks.